Cerebrotendinous xanthomatosis presenting with bilateral achilles tendon xanthomata: a case report.

Xanthomas are described as deposits in the skin and subcutaneous tissues. Mostly known as pseudotumors, xanthomas consist of connective tissue containing mainly cholesterol, triglycerides, and numerous foamy macrophages. Bilateral Achilles tendon xanthomata is pathognomonic for cerebrotendinous xanthomatosis in the case of normal cholesterol levels but increased cholestanol levels in serum. In this article, we present findings regarding bilateral xanthomas of Achilles tendons in a patient with cerebrotendinous xanthomatosis.

Giant sacral schwannoma: a case report and review of the literature.

Intraspinal schwannomas localized in the sacrum are relatively infrequent, accounting for 1-5% of all spinal axis schwannomas. They frequently grow to considerable size before detection; hence, the term giant sacral schwannoma. Sacral schwannomas arise from the sacral nerve roots. The diagnosis of schwannomas in the spinal canal is difficult because of their slow growth, often resulting in extensive bony destruction. This case report documents the management of a 48-year-old male with a giant sacral schwannoma. We performed a two-stage surgery with intralesional tumour resection. The patient is now free of any complaint, complications and there is no recurrence two years after resection of the schwannoma. Intralesional excision of a sacral schwannoma is a less invasive procedure than total or partial sacrectomy. Using a combined anterior and posterior approach, satisfactory tumour excision and stabilization can be achieved, while avoiding the high morbidity related with total sacrectomy.

Posterior vertebrectomy in kyphosis, scoliosis and kyphoscoliosis due to hemivertebra.

Vertebrectomy and instrumentation only via the posterior approach has been increasingly used in sagittal, frontal plane and combined deformities. The aim of this retrospective study is to evaluate the clinical and radiological results of hemivertebrectomy and instrumentation only via the posterior approach in congenital spinal deformities. Between 1998 and 2003, we performed hemivertebrectomy and interbody fusion using posterior instrumentation with titanium mesh cage via the posterior approach in 19 patients (three scoliosis, five kyphosis and 11 kyphoscoliosis). The age of the patients ranged from 2 to 22 years and they all underwent hemivertebrectomy (at thoracic level in six patients, at thoracolumbar level in eight patients and at lumbar level in five patients). A titanium mesh cage was used for anterior column support and interbody fusion in patients who had residual anterior gap preventing bone-to-bone contact. Correction and stabilization were achieved by posterior polyaxial pedicle screws. Follow-up was an average of 4.6 years (range: 2-7 years). We did not confront any loss of correction, pseudoarthrosis, and titanium mesh cage collapse or implant failure. Hemivertebrectomy and instrumentation via the posterior approach is a good one-stage surgical treatment option that can be used to avoid the surgical trauma and morbidity related to anterior surgery. It is a technically demanding surgical procedure, however, requiring extreme care and experience in spine surgery.

Comparative analysis of pedicle screw versus hybrid instrumentation in adolescent idiopathic scoliosis surgery.

The expectations of both the patient and surgeon have been greatly revised in the last 10 years with the introduction of pedicle screws (PS) in spinal surgery. In this study, we have retrospectively evaluated and compared the results of PS instrumentation and the Hybrid System (HS), the latter consists of pedicle screws, sublaminar wire and hooks. The mean follow-up period was 60.1 months (range: 49-94 months) for the patients of the HS group and 29.3 months (range: 24-35 months) for those of the PS group. In the HS group, pedicle screws were used at the thoracolumbar junction and lumbar vertebra, the bilateral pediculotransverse claw hook configuration was used at the cranial end of the instrumentation, sublaminar wire was used on the concave side of the apical region and the compressive hook was used on the convex side. In the PS group, PS were used on the concave sides at all levels and on the convex side of the cranial and caudal end of instrumentation, in the transition zone and at the apex. The two groups were comparable for variables such as mean age, preoperative Cobb angle, thoracic kyphosis angle, lordosis angle, coronal balance, flexibility of the curve, apical vertebra rotation (AVR), apical vertebra rotation (AVT) and the number of vertebrae included in the fusion (p>0.05). The parameters of values of correction, ratio of correction loss, AV derotation, AVT correction ratio, amount of blood loss, operation time, postoperative global coronal and sagittal balance, thoracic kyphosis angle and lumbar lordosis angle were measured at the last follow-up and used for comparing the HS and PS groups. There was no statistically significant difference between the groups for correction ratio, postoperative coronal balance, postoperative thoracic kyphosis and lumbar lordosis angle, operation time, amount of blood loss and number of fixation points (p>0.05) The difference for the ratio of correction loss, AV derotation angle and the AVT correction ratio at the last follow-up visit and for the total follow-up period between the groups was found to be statistically significant (p<0.05). Although it is possible to obtain a similar amount of correction by either instrumentation system, the loss of correction seems to be lower with the more rigid PS construction. The PS system also has a stronger effect on vertebral bodies, thereby providing better AV de-rotation. There was no significant difference (p>0.05) between the groups in terms of correction rate, postoperative coronal and sagittal balance, operation time, blood loss and number of fixation points. This may indicate that anchor points are more important than the use--or not--of screws. Correction durability and AV de-rotation was better with PS instrumentation, while AVT was better corrected by HS instrumentation (p<0.05). We propose that the reason for the better correction of AVT with HS instrumentation is the forceful translation offered by the sublaminar wire at the apical region, while the reason for the better correction durability of the PS instrumentation may be due to the fact that multiple pedicle screws which afford three-column control are better at maintaining the correction and preventing late deterioration.

A 13-year-old textiloma (gossypiboma) after discectomy for lumbar disc herniation: a case report and review of the literature.

BACKGROUND CONTEXT: A paraspinal retained surgical sponge (textiloma) is rare and mostly asymptomatic in chronic cases but can be confused with other soft-tissue masses. Therefore, it is important to be aware of patients with a paraspinal soft-tissue mass with unusual or atypical symptoms. PURPOSE: A patient with asymptomatic chronic paraspinal textiloma who was operated on 13 years ago for lumbar disc herniation is presented. STUDY DESIGN: Case report. METHODS: A patient presented with complaints of back pain radiating to leg and neurogenic claudication. Computed tomography imaging revealed canal stenosis at L3-L5 levels and a soft-tissue mass at the paraspinal muscles of the L5-S1 level. RESULTS: Surgical treatment was performed for both to excise or obtain biopsy from the soft-tissue mass and to treat spinal stenosis. During the operation, a retained surgical sponge was found and excised completely with fibrous capsule surrounding it and decompression and posterior spinal instrumentation performed without fusion for spinal stenosis with dynamic pedicle screws (Cosmic Pedicle Screw System; Ulrich AG, Germany). Recovery was uneventful, and the patient's stenosis symptoms were resolved soon after surgery. CONCLUSION: Retained surgical sponges do not show mostly any specific clinical and radiological signs. They should be included in differential diagnoses of soft-tissue masses at the paraspinal region with a history of a previous spinal operation.

Treatment approach in tandem (concurrent) cervical and lumbar spinal stenosis.

Spondylotic degeneration can manifest as tandem (concurrent) cervical and lumbar spinal stenosis. The primary manifestations include neurogenic claudication, gait disturbance and a mixture of findings of myelopathy and polyradiculopathy in both the upper and lower extremities. The purpose of this retrospective study was to report the existence and management of tandem (concurrent) cervical and lumbar spinal stenosis. Between 1998 and 2004, 8 patients (6 women and 2 men) were diagnosed with tandem spinal stenosis in a series of 230 patients who underwent surgery for spinal stenosis (3.4%). Three patients received cervical surgery first and 5 patients lumbar surgery first. The Japanese Orthopaedic Association Score of all patients improved from an average of 8.1 preoperatively to an average of 11.8 points at discharge and maintained an average of 12.7 points at final follow-up. Oswestry Disability Score improved from mean 58.1 to 29 at discharge and 19.3 at latest follow-up. All the patients had excellent or good results and none deteriorated neurologically. Although tandem spinal stenosis occurred relatively infrequently, we concluded that its possible presence should not be overlooked. The treatment plan must be designed according to the chief complaints and symptoms of the patient.

[Total disc prosthesis for painful degenerative lumbar disc disease]. / Lomber dejeneratif disk hastaligii total disk protezi ile tedavisi.

OBJECTIVES: We evaluated clinical and radiographic results of patients treated by the ProDisc II total disc prosthesis (TDP) for painful degenerative lumbar disc disease. METHODS: The study included 34 patients (25 females, 9 males; mean age 44 years; range 37 to 54 years) who underwent a total of 62 lumbar TDP procedures for degenerative lumbar disc disease. Lumbar disc replacement involved one level in 12 cases, two levels in 17 cases, three levels in four cases, and four levels in one case. Clinical and radiographic assessments were made preoperatively and at 3, 6, 12, and 24 months postoperatively. Clinical evaluations were made with a visual analog scale (VAS) and the Oswestry Disability Index (ODI). Radiographic parameters included lumbar lordotic angle, the height and flexion-extension range of the affected discs. The mean follow-up period was 29.3 months (range 24 to 39 months). RESULTS: Low back pain and lower extremity pain showed near-complete improvement up to the third postoperative month. At the end of the 24th month, preoperative ODI and VAS scores of 59.6 and 7.8 decreased to 19.8 and 1.0, respectively. Preoperative and postoperative lumbar lordotic angles were 52.6 degrees and 57.1 degrees , respectively. The mean disc height of implanted discs increased from 4.6 mm to 12.1 mm postoperatively. The mean flexion-extension angle increased from 2.8 degrees to 8.4 degrees at L5-S1, and from 2.6 degrees to 9.8 degrees at L4-5. The overall improvement in the mean flexion-extension angle was 7.2 degrees . CONCLUSION: Lumbar disc prosthesis offers significant advantages in terms of functional improvement and increased quality of life in the surgical treatment of degenerative disc disease.

An uncommon cause of paraplegia: Salmonella spondylodiskitis.

BACKGROUND/OBJECTIVE: Salmonella spondylodiskitis is an uncommon type of vertebral infection. The aim of this study was to present a case of progressive paraplegia caused by Salmonella spondylodiskitis and epidural abscess after endoscopic cholecystectomy. METHODS: The patient underwent posterior instrumentation and posterior fusion between T6 and T12, hemilaminotomies at levels T8-T9-T10, and drainage of the abscess. Through a left thoracotomy, anterior T8-T10 corpectomy, debridement, anterior stabilization, and fusion were conducted. RESULTS: Fifteen months later, final follow-up showed no complications secondary to the vertebral and hip surgeries, and neurological status improved to Frankel grade E. Laboratory investigations showed no evidence of Salmonella infection. CONCLUSION: Immunocompromised patients who undergo endoscopic intervention are vulnerable to Salmonella infections. One must consider Salmonella infection in those who develop acute progressive spondylodiskitis.

Assessment of curve flexibility in adolescent idiopathic scoliosis.

STUDY DESIGN: A prospective comparative evaluation of the commonly accepted or described radiologic techniques to determine curve flexibility in adolescent idiopathic scoliosis (AIS), comparison of the results to those obtained by supine traction radiographs taken with the patient under general anesthesia (UGA) just before surgery and correlation of all findings to surgical correction. OBJECTIVE: To determine if supine traction radiographs taken with the patient UGA help provide better assessment of curve flexibility and better predicting surgical correction. SUMMARY OF BACKGROUND DATA: Supine lateral bending radiographs are the standard methods of evaluating curve flexibility before surgery in idiopathic scoliosis. Supine traction radiographs have also been used at the authors' institution in addition to the supine lateral bending radiographs before surgery, believing that it is usually more helpful to analyze the response of the main and compensatory curves to corrective forces. METHODS: A total of 34 consecutive patients with AIS who had surgical treatment were studied. Preoperative radiologic evaluation consisted of standing anteroposterior and lateral, supine lateral bending and traction, fulcrum bending radiographs, and also supine traction radiographs taken with the patient UGA just before surgery. All structural curves were measured, and the flexibility ratio was determined on each radiograph. The amount of correction obtained by all radiographic methods was compared with the amount of surgical correction by evaluating the differences from surgery as absolute values. Mean absolute differences from surgery were used to determine the confidence intervals. Statistical differences were calculated with the comparison of the exact 95% confidence intervals for the mean. RESULTS: Curves were accepted to be moderate if between 40 degrees and 65 degrees (29 patients) and severe if >65 degrees (5 patients). In these 29 patients, average frontal Cobb angle of the thoracic and lumbar curves were 49.7 degrees (range 40 degrees-60 degrees) and 39.4 degrees (range 22 degrees-58 degrees), respectively. For the moderate thoracic curves, fulcrum radiographs provided the best amount of flexibility, with no significant difference from traction with the patient UGA but with significant difference from bending radiographs. For the moderate lumbar curves, flexibility obtained by fulcrum and bending radiographs were significantly better than traction radiographs with the patient UGA. For the lumbar and thoracic curves more than 65 degrees, traction radiographs with the patient UGA provided clearly better flexibility compared to bending and fulcrum radiographs, however, the number of patients is not enough to determine whether the differences are statistically significant. Better flexibility in traction radiographs with the patient UGA helped us eliminate the need for anterior release in all 5 patients who had severe and rigid curves more than 65 degrees, which did not bend to less than 40 degrees and were planned to have anterior release. CONCLUSION: Fulcrum higher than bending higher than traction with the patient UGA is the order of radiographs for better predicting flexibility and correction in curves between 40 degrees and 65 degrees. Flexibility obtained at traction radiographs with the patient UGA is clearly better in numerical values, and closer to the amount of surgical correction than the amount of flexibility at fulcrum and side-bending radiographs for curves larger than 65 degrees, although not statistically significant as a result of the small number of patients in this group. However, pedicle screw instrumentation provides even more correction than the traction radiographs with the patient UGA. Thus, traction radiographs with the patient UGA may show much better flexibility, especially in more than 65 degrees and rigid curves.

[Cervical spine injuries in children]. / Cocuklarda servikal omurga yaralanmalari.

Cervical spine injuries in children and adolescents are rare. Common mechanisms include motor vehicle accidents, sports injuries, fall from height, and gunshot injuries. Cervical spine injuries are classified by Allen and Ferguson according to the period they occur, as infantile, early juvenile, and late juvenile. Anatomically, two main types are defined as occipitoatlantal (upper cervical) and subaxial injuries. The purpose of this paper is to review cervical spine injuries in children and adolescents with respect to epidemiology, injury mechanisms, diagnosis, clinical and radiologic aspects, and treatment in the light of the current literature.